Community Approaches to Prevention and Early Intervention

1. Community Approaches to Prevention and Early Intervention Jan Campbell, R.N., B.S.N. Sue Spooner, R.N., C.P.N.P. January 2007

2. “Hand of Hope” The tiny hand of 21-week-old fetus Samuel Alexander Armas emerges from the mother’s uterus to grasp the finger of Dr. Joseph Bruner.

3. The Problem Perinatal Substance Abuse

4. National Pregnancy and Health Survey • Illicit drugs 5.5% • Cocaine 1.9% • Marijuana 2.9% • Alcohol 18.8% • Tobacco 20.4%

5. CRT vs. SAMHSA Data:Substance Use in Pregnancy

6. Riverside CountySubstance-Exposed Babies • Preliminary data indicate 13% of women screen positive for substance use • In 2004, there were 29,545 births • Applying 13%, which is considered a low estimate, 3,841 babies were born exposed to drugs and/or alcohol

7. San Luis Obispo CountySubstance-Exposed Babies • Preliminary data indicate 38.5% of women screen positive for substance use • In 2005, there were 2,640 births • Applying 38.5% which is considered a low estimate, 1,016 babies were born exposed to drugs and/or alcohol

8. Substance Use Rates Across California Counties

9. Alcohol Use Patterns After Knowledge of Pregnancy:San Luis Obispo, Riverside vs. CA

11. Predictors of Low Birth Weight Tobacco has a 3x greater impact than cocaine on predicting low birth weight

12. Tobacco Decreases oxygen to fetus Baby is born too early Small babies (low birth weight) Nicotine withdrawal More likely to die from SIDS Learning and behavioral problems

13. Marijuana • Right after birth • Hard time responding • Shakes • Hard time comforting • Long-term affects • Trouble paying attention • Aggressive behaviors

14. Baby Exposed to Cocaine

15. Cocaine, Methamphetamines, Heroin Drugs can starve parts of the baby’s body and prevent it from growing Can cause stroke or heart attack in the womb Can cause miscarriage, early birth and nervous system problems SIDS Learning and behavioral problems

16. Alcohol • Low birth weight • Small brain with brain damage • Heart problems • Kidney problems • Malformations • Facial dysmorphology

17. Newborn baby boy with pronounced features of FAS and severe heart disease.  Birth weight and length less than 5th percentile for gestational age.

18. Prenatal alcohol exposure is the leading preventable cause of birth defects, developmental disorders, and mental retardation in children Journal of the National Association of Neonatal Nurses 2005

19. Cause of FAS/FASD • The sole cause of FAS/FASD is women drinking alcoholic beverages during pregnancy. • Alcohol is a teratogen. “ Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effect in the fetus” IOM report to Congress 1996

20. FASD Facts • 100 percent preventable • Leading cause of preventable mental retardation • Not caused on purpose • Can occur anywhere and anytime pregnant women drink • Not caused by biologic father’s alcohol use • Not a new disorder

21. FASD and the Brain • Prenatal alcohol exposure causes brain damage. • Effects of FASD last a lifetime. • People with an FASD can grow, improve, and function well in life with proper support.

22. FAS and the Brain

23. Effects of Alcohol on the Brain

24. FAS: CNS Effects • Mental retardation • Developmental delays • Hyperactivity • Behavior problems • Speech/language dysfunction

25. People with FASD have difficulty: • Following instructions • Discerning the difference between truth and fiction • Thinking about abstract concepts • Organizing • Storing and retrieving information • Understanding social expectations • Comprehending and responding to other people’s feelings • Bonding or building personal attachment and trust

26. Alcohol Dose • 1 drink/week • Hyperactive and aggressive behaviors • Moderate to heavy use • Delinquent behavior and overall problem behavior • Any alcohol use pregnancy • 3.2 x risk for delinquent behavior

27. Comparing FASD to OtherBirth Defects

28. Estimated Number of FAS • Fetal Alcohol Syndrome (FAS) 1 in 500 births • Combined estimated number of FASD 5 in 500 births Journal of the National Association of Neonatal Nurses 2005

29. Economic Cost of FAS • Cost the nation $5,400,000,000 in 2003. • Each individual with FAS will cost US $1,500,000 to $3,000,000 in his or her lifetime.

30. Message If you are pregnant or think you could be pregnantDO NOT USE ANY: • Alcohol (beer, wine, liquor) • Tobacco/Marijuana • Illicit drugs (methamphetemines, heroine, cocaine)

31. What Now?

32. Community Collaboration Development of a Community Team

33. Who Should be on a Community Team? • People with passion • Respected leaders in the community • People with passion • People with the authority to commit resources and make decisions • People with passion

34. Community Team Considerations • Knowledge • Obstetrics • Public Health Nursing • Child Protective Services • Mental Health • Substance Abuse Treatment • Healthy Start ( if it exists in the community) • Community orientation • Authority and influence • Size • Compatibility • Consumer representation

35. Director Maternal and Child Health Director Mental Health Director Substance Abuse Treatment Director Child Protective Services Director Healthy Start Public Health Nursing Obstetrician Pediatrician County Board of Supervisors Presiding Judge, Drug Dependency Court Community Team Example

36. The Community Team Considerations • Make sure there is representation from “the basic six” • Recruit people with a community orientation • Seek people who are respected in the community • Invite those with authority of influence • Keep the group a manageable size: 8-12 • Make sure team members are compatible • Involve consumers in a useful and respectful way

37. The Leadership Institute • A 3½ day learning and planning experience • Intended to give the team a shared understanding of the key issues in substance use among pregnant and parenting women • Designed to produce an initial plan for the team to use as the members return to their community

38. The Core Intervention

39. Where Do We Start?

40. Successful Implementationof a Perinatal Screening, Assessment, Referral and Treatment Program

41. How Do We Begin? Build your support services • Referral and treatment • Mental Health • Drug and Alcohol • Private psychologist and therapist

42. Training • It is important to train your provider prior to implementation of the SART Program • Dinner with providers and wives/husbands • Key note speaker - a physician knowledgeable and respected in the area of perinatal substance use

43. Establish a Good Support System • Needs to be integrated as a routine part of prenatal care (not a psychosocial issue but a health issue) • This is a health issue for all pregnant women • Present the program as a complete package • Provide assessment forms • Instructions/staff training (ongoing basis) • Collection of Data • Educational Materials • “I am concerned” brief intervention • Pamphlets

44. Referral Process • Easy to use • Clear easy to use forms • Minimal information to fill out • Contact numbers answered by a person • Followed up in a timely manner • Contact clients within 2 to 3 days • Feedback to the physician • Respond back to referring physician regarding outcome of referral

45. Share Data • Give feedback on screening data to physician on a regular basis • Physician’s practice compared to overall county results

46. Value of Respect • Respect professionalism of OB providers by • Providing scientific proof • Best Practices • Respect provider’s time by • Bringing all necessary materials • Providing training and ongoing support • Respect provider as a partner by • Visiting as often as necessary • What can we do for you

47. Respect provider’s commitment to SART by Acknowledging their contribution Respect provider’s commitment to their patients’ means Providing accurate and timely feedback Respect provider’s interest in real results means Working with other agencies to make sure referrals are acted upon

48. What does a screening program look like?

49. The SART System • Screening • Assessment • Referral • Treatment

50. Screening • ParentsDid either of your parents ever have a problem with alcohol or drugs? • PartnerDoes your partner have a problem with alcohol or drugs? • PastHave you ever drunk alcohol? • Pregnancy • In the month before you knew you were pregnant, how many cigarettes did you smoke? • In the month before you knew you were pregnant, how many beers did you drink? • In the month before you knew you were pregnant, how much marijuana did you smoke?